SLP see reverse Kindergarten Registration Questionnaire (Revised October 2015) Page 1

Kindergarten Communication Questionnaire This information will be used by Peel District School Board staff to better meet the needs of your child.

Child’s Name:

Child’s Date of Birth: (yyyy/mm/dd)

Parent Name:

Parent Phone Number:

Languages Spoken in the Home:

Please answer the following questions based on the language that you and your child speak at HOME:

1. What age did your child begin to talk using single words? (e.g., "no," "more") ____________

2. Did your child combine words by two years of age and use simple sentences by three years of age? Yes No

3. Does your child speak in complete sentences using age-appropriate grammar? Yes No

4. Does your child stutter, stammer or struggle to get words out when talking?

(e.g., repeats words many times; stretches or repeats the first sound in a word such as mmmmmmme or c-c-c-c-cat) Yes No

5. Can your child talk about things they or others have done in the right order? Yes No

6. Can your child follow 2-3 simple directions given at once?

(e.g., "Put your blocks away, turn off the TV and get your coat.") Yes No

7. Can your child ask and/or answer questions correctly? Yes No

8. Does your child pronounce words clearly in his/her HOME language similar to others his/her age? Yes No

9. Do people outside the family understand most of what your child says? Yes No

10. Does your child engage in step-by-step pretend play? (e.g., pretending to be a teacher, pretending to give a doll a bath) Yes No

11. Has your child ever received speech/language support?

(e.g., Erinoakkids, private speech and language services, etc.) Yes No

If yes, is there a report you can share with the school? Yes No

12. Do you have any concerns about your child's speech and language development? Yes No If yes, please describe________________________________________________ __________________________________________________________________ __________________________________________________________________

SLP see reverse Kindergarten Registration Questionnaire (Revised October 2015) Page 2

Please share any additional information that would help us get to know your child.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

SCHOOL USE ONLY Reviewed by School SLP ____________________________________________________________________

SLP Follow-up:

� Called parent to discuss information

� Referred parent to community resources (e.g., Ontario Early Years Centre, Child and Family Resource

Centre, etc.)

� Referred parent to ErinoakKids

� Suggested hearing evaluation

� Suggested medical follow-up

� Provided resources to parents

� Other

Any other additional information:

Parent Registration Checklist

In all instances, ORIGINAL documentation or officially certified true copies must be presented.

Student Currently Registered with the Peel District School Board ~ Required:

Transfer form (Elementary) or Status Sheet (Secondary) from previous Peel District School Board school

Proof of Address (see list below)

Completed Registration Form

Student Not Currently Registered with the Peel District School Board ~ Required:

Proof of child's age and citizenship/eligibility (present one original document from the list below)

Canadian Birth Certificate/Birth Registration Card

Canadian Citizenship Card / Certificate / Passport

Permanent Resident Card / Confirmation of Permanent Residence

Work permit/Employment Authorization from Citizenship and Immigration Canada

Study Permit issued to parent for a diploma or degree program from Citizenship and Immigration

Canada

Refugee/Convention Refugee Permit

Visitor Permit for Missionary Work (only case type 13)

Proof of address (present one original document from the list below)

Utility Bill (water, hydro, gas, phone, cable, cell phone)

Bank Statement/Letter from Financial Institution

Credit Card Statement

Government forms (i.e. Service Canada, Ontario Works or Canada Post change of address)

Purchase Agreement

Other Government Identification (e.g. Ontario Photo Card)

Please note that a driver’s license cannot be accepted.

Proof of immunization

Students registering in an Ontario public school for the first time must provide proof of immunization/vaccination or valid Exemption from Peel Health. Parents are encouraged to report your child’s immunization online at www.peelregion.ca/immunize and provide the reference number to your child's school on the student registration form.

Students with an Ontario Education Number (shown on Ontario report cards or transcripts) do not need to provide proof of immunization

Proof of custody – children must live with their parent(s) unless provided documentation supports an

alternate living arrangement

Proof of education

For Elementary students who are currently attending school in Ontario, please bring the most re-cent report card

For Secondary students who are attending or have attended secondary school in Ontario, please bring the most recent transcript, report card or credit summary report (if available)

Notify school at time of registration if your child is registered currently in a specialized program such as SHSM (include sector), IB, IBT, FI, EF, ELL or other programming

Provide a copy of your child’s most recent IEP, if applicable.

Completed Registration Form

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January 2020

S T U D E N T I N F O R M A T I O N

R E S I D E N T I A L A D D R E S S

M A I L I N G A D D R E S S

G E N E R A L S T U D E N T I N F O R M A T I O N ( M u s t b e c o m p l e t e d i n f u l l )

H E A L T H F A C T O R S ( M u s t b e c o m p l e t e d i n f u l l )

STUDENT NUMBER (If Transfer)

ONTARIO EDUCATION NUMBER (OEN) GRADE/HOME FORM ADMISSION DATE (yyyy-mm-dd) GR 9 ENTRY DATE (yyyy-mm-dd)

LEGAL LAST NAME

LEGAL FIRST NAME MIDDLE NAME GENDER MALE

USUAL LAST NAME

PREFERRED FIRST NAME BIRTH DATE (yyyy-mm-dd) FEMALE

OTHER

HOME PHONE NUMBER ( )

UNLISTED

YES APT. NO. STREET/EMERGENCY NUMBER STREET NAME/LINE OR SIDE ROAD

P.O. BOX TOWN/CITY PROVINCE POSTAL CODE

IF DIFFERENT THAN RESIDENTIAL ADDESSS

APT. NO.

STREET NUMBER STREET NAME/LINE OR SIDE ROAD

P.O. BOX TOWN/CITY

POSTAL CODE

PREVIOUS SCHOOL DISTRICT PREVIOUS SCHOOL NAME PREVIOUS SCHOOL ADDRESS

PROOF OF AGE & NAME (copy for OSR)

CDN. BIRTH CERTIFICATE/ REGISTRATION CARD CDN. PASSPORT

CANADIAN CITIZENSHIP CARD

PERMANENT RESIDENT CARD/FORM

OTHER IMMIGRATION DOC _________________________

FOR FUNDING PURPOSES ONLY

Country of Birth Province/Territory 1st Entry Date into If Canada Canada (yyyy-mm-dd)

______________________ ______________________ ________________________

WAS ENGLISH FIRST LANGUAGE STUDENT

LEARNED AT HOME? YES NO LANGUAGES STUDENT SPEAKS AT HOME ___________________________ __________________________ __________________________

VOLUNTARY AND CONFIDENTIAL SELF-IDENTIFICATION FOR FIRST NATION, MÉTIS, AND INUIT STUDENTS FIRST NATION MẾTIS INUIT

HEALTH FACTORS

ASTHMA - Life Threatening YES NO

SEIZURES - Life Threatening YES NO

DIABETES - Life Threatening YES NO

ALLERGIES ___________________________________ Life Threatening YES NO

OTHER _______________________________________ Life Threatening YES NO

Medication Required at School? YES NO (If yes, Medication Form must be completed)

Immunization Required: Peel Health Immunization Reference # PEEL- __ __ __ __ __ __ __ __ __ (9 alphanumeric digits)

OR Peel Health Exemption #

PEEL- __ __ __ __ __ __ __ (7 alphanumeric digits)

S T U D E N T R E G I S T R A T I O N F O R M

S H A D E D A R E A S F O R S C H O O L U S E O N L Y

CUSTODY

BOTH PARENTS

*Documents Required

*FATHER ONLY

*SELF (16 & OVER)

LIVING WITH

BOTH PARENTS

FATHER ONLY

SELF

*MOTHER ONLY *LEGAL GUARDIAN(S) *CHILDREN’S AID SOCIETY MOTHER ONLY LEGAL GUARDIAN(S) FOSTER PARENT(S)

MOTHER GUARDIAN

FATHER SELF

Last Name First Name Speaks English

YES NO

Home Phone Number ( )

Cellular Number ( )

Business Phone Number (including Ext.) ( )

E-mail Address*

MOTHER GUARDIAN

FATHER SELF

Last Name First Name Speaks English

YES NO

Home Phone Number ( )

Cellular Number ( )

Business Phone Number (including Ext.) ( )

E-mail Address*

Address if different from student (include street number, name, city and postal code)

If parent is deceased:

Parent: Date of Death ___________________________________________ Parent: Date of Death ___________________________________________

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S I B L I N G I N F O R M A T I O N ( M u s t b e c o m p l e t e d i n f u l l )

E M E R G E N C Y C O N T A C T S I F P A R E N T ( S ) / G U A R D I A N ( S ) U N A V A I L A B L E — I N O R D E R O F A V A I L A B I L I T Y ( # 1 E A S I E S T T O C O N T A C T )

*CONSENT TO RECEIVE ELECTRONIC COMMUNICATION FROM THE PEEL DISTRICT SCHOOL BOARD

I hereby consent to receive electronic communication from the Peel District School Board at the email address I have provided. I understand this consent will be

effective for the duration of my child’s education at the board. I understand this information may be shared with the School Council (co-)chair(s) for my child’s schools for the purposes of sending School Council information to me via email.

You may withdraw your consent and unsubscribe from our communications at any time by clicking the unsubscribe link in any future email, or by contacting your child’s school or the board office at 905-890-1010.

I CONFIRM THAT OUR FAMILY IS A PUBLIC SCHOOL SUPPORTER.

YES NO If no, reason. ________________________________________________________________

IF THE CHILD IS NOT A PEEL DISTRICT SCHOOL BOARD STUDENT, I AGREE THAT THE PEEL DISTRICT SCHOOL BOARD MAY CONTACT MY CHILD'S FORMER SCHOOL TO COLLECT INFORMATION FOR PURPOSES CONSISTENT WITH THE BOARD'S LEGISLATED RESPONSIBILITIES AND AUTHORITY.

YES NO If no, reason. _______________________________________________________________

IS THE STUDENT CURRENTLY SERVING A SUSPENSION OR EXPULSION?

YES NO If yes, which school and reason for suspension/explusion. ______________________________________________________________

REGISTRATION IS CONDITIONAL UPON RECEIPT OF ONTARIO STUDENT RECORD FROM SENDING SCHOOL TO CONFIRM APPROPRIATENESS OF ADMISSION.

PARENT/GUARDIAN OR STUDENT (18 OR OLDER) DATE

LAST NAME FIRST NAME RELATIONSHIP TO STUDENT DATE OF BIRTH SCHOOL & GRADE

BROTHER SISTER

BROTHER SISTER

BROTHER SISTER

BROTHER SISTER

BROTHER SISTER

For additional siblings, please add siblings on a separate sheet of paper and include with registration form

1. LAST NAME

2. LAST NAME 3. LAST NAME

FIRST NAME

FIRST NAME FIRST NAME

RELATIONSHIP TO STUDENT:

RELATIONSHIP TO STUDENT:

RELATIONSHIP TO STUDENT

HOME PHONE NUMBER ( )

CELLULAR NUMBER ( )

HOME PHONE NUMBER ( )

CELLULAR NUMBER ( )

HOME PHONE NUMBER ( )

CELLULAR NUMBER ( )

BUS. PHONE NUMBER & EXTENSION ( )

SPEAKS ENGLISH YES NO

BUS. PHONE NUMBER & EXTENSION ( )

SPEAKS ENGLISH YES NO

BUS. PHONE NUMBER & EXTENSION ( )

SPEAKS ENGLISH YES NO

ADDITIONAL FAMILY INFORMATION OF WHICH SCHOOL SHOULD BE AWARE: PLEASE ADVISE IF ALTERNATE COMMUNICATION (e.g. HARD OF HEARING, LARGE PRINT, BRAILLE, SIGN LANGUAGE) REQUIRED

Municipal Freedom of Information and Protection of Privacy Act: Personal information on this form is collected under the legal authority of the Education Act, R.S.O. 1990, c.E-2, as amended. This information will be used for the Ontario Student Record and for administrative purposes. Questions regarding this collection should be directed to the Principal or Freedom of Information Co-ordinator, Peel District School Board, 5650 Hurontario Street, Mississauga, Ontario, L5R 1C6. Tel: 905-890-1010, ext. 2019.

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Proof of Age and Immigration Status Canadian Birth Certificate/Registration Card Canadian Citizenship Card/Certificate/Passport Canadian Permanent Resident Card/Confirmation of

Permanent Residence Application and Receipt for Sponsorship (Applicant

for Landing) Stage 1 Confirmation Letter from CIC

Proof of Address/Residence in Peel Government Issued Forms Utility Bill Bank Statement/Letter from Financial Institution Credit Card Statement Purchase Agreement

Immunization Records (only required for students without an OEN #) Ontario Yellow Immunization Card Immunization Record from elsewhere Peel Health Reference Number or Peel Health

Exemption Reference Number from online reporting Language Information (for funding and emergency purposes) Country of Birth _______________________ Province/Territory of Birth (if Canada)__________ 1st Entry Date into Canada __________________ Parent speaks English Yes No Was English first language student learned at home Yes No

Proof of Custody (where applicable) Living with custodial parent(s) Cdn. Custodial Court Order Peel Guardianship Agreement

Work Permit/Parent Study Permit (for diploma or degree)

Visitor Permit for Missionary Work (only case type 13) Refugee Permit/Convention Refugee Expired Visitor Permit Fee Paying (via Peel Schools for International Students) Exchange Students (see OP—CISS 9 prior to registering) Attach a copy of the Proof of Age and Immigration Status document to this Registration Form I certify that I have seen this document Date: ____________________ Initial: ____________________ I certify that I have forwarded to Peel Health Date: ____________________ Initial: ____________________ I certify that I have checked this information Date: ____________________ Initial: ____________________ I have reviewed and attached the required documentation (if applicable) Date: ____________________

SCHOOL CHECKLIST FOR STUDENT REGISTRATION (to be completed by School Staff)

Additional Documentation Report Card Transcript and/or Credit Summary Report (secondary students) IEP (if applicable) Other Program Documentation Multicultural, Settlement & Education Partnership (MSEP) Consent – signed

I verify that I have either seen all of the documents listed personally, or the validity of the documents that I did not see per-

sonally has been confirmed to me as required by Operating Procedure – LDSS 1 The Registration, Admission and Withdrawal

of Students. I have attached to this form the Registration Form, copy of Proof of Age and Immigration Status and the custody

order (if applicable). I have ensured that all information on the registration form is complete and entered all fields on SIS.

Certified by: ____________________________ ____________________________ ___________________

Print name Signature Date

Legal

Last

Name

Legal

First

Name

Peel SIS #

OEN #

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In all instances, ORIGINAL documentation or officially certified true copies must be presented.